Provider Demographics
NPI:1225235906
Name:RUDDELL CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:RUDDELL CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:RUDDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-743-8401
Mailing Address - Street 1:1117 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-3739
Mailing Address - Country:US
Mailing Address - Phone:208-743-8401
Mailing Address - Fax:208-743-8722
Practice Address - Street 1:1117 16TH AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-3739
Practice Address - Country:US
Practice Address - Phone:208-743-8401
Practice Address - Fax:208-743-8722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-503111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805054900Medicaid
ID1673019Medicare ID - Type Unspecified